Dental Materials Journal 2019; 38(6): 970–980

Influence of immediate dentin sealing and temporary restoration on the bonding

of CAD/CAM ceramic crown restoration
Kotaro HAYASHI, Masahiko MAENO and Yoichiro NARA

Department of Adhesive Dentistry, School of Life Dentistry at Tokyo, The Nippon Dental University, 1-9-20 Fujimi, Chiyoda-ku, Tokyo 102-8159,
Japan
Corresponding author, Masahiko MAENO; E-mail: mmaeno@tky.ndu.ac.jp

This study examined the influences of clinical application of immediate dentin sealing (IDS) and temporary restoration (TR) on
prepared abutment surfaces on the bonding of computer-aided design/computer-aided manufacturing (CAD/CAM) ceramic crown
restorations after cyclic loading. Standardized abutments were prepared in 60 human mandibular premolars. Dentin surfaces of half
of the specimens were sealed with adhesive and flowable composite, while those of the other half were not sealed. A half of both sealed
and non-sealed specimens were restored using a temporary cement and temporary crown. Each individual CAD/CAM ceramic crown
was fabricated and cemented to an individual abutment. The restored specimens were subjected to cyclic loading, and the micro
tensile bond strengths (μ-TBS) were measured. IDS contributed to an increase in the bond strength, whereas TR did not affect the
bond strength. IDS restoration without TR yielded the maximum bond reliability in achieve specific μ-TBS values for the restoration
and ensuring durability against debonding.

Keywords: CAD/CAM restoration, Immediate dentin sealing, Temporary restoration, Microtensile bond strength, Weibull analysis

is necessary for the abutment tooth during crown

INTRODUCTION
Computer-aided design/computer-aided manufacturing
(CAD/CAM) technology has recently begun to be
employed in dental clinical practice. Conventional
indirect restorations, such as cast gold restorations,
require complex procedures. However, CAD/CAM
restorations created using digital data taken from optical
impressions can simplify these procedures. The latest
CAD/CAM systems are especially capable of fabricating
high-quality and uniform inlay/onlay/crown efficiently.
Nevertheless, metal-free CAD/CAM restorations require
robust adhesion between the tooth substance and the
fabricated inlay/onlay/crown to obtain an excellent
prognosis1). Immediate dentin sealing contributes to
improved adhesion2), enhanced adaptation3), and the
protection of the dentin pulp complex4) in inlay/onlay
restorations. However, the efficacy of immediate dentin
sealing with adhesive systems and flowable resin
composites on metal-free CAD/CAM crown restorations
has not been examined. Metal-free crown restorations
for vital teeth may cause pulp damage, i.e., inflammation
and necrosis, because of the substantial reduction in
tooth substance as a result of the abutment preparation
process5). Therefore, establishment of an application
method for immediate dentin sealing of metal-free crown
restorations should provide benefits in clinical practice.
Chair-side CAD/CAM systems allow one-day
treatment6,7). In contrast, laboratory CAD/CAM
restorations that are fabricated in the laboratory using
digital data obtained with an intraoral scanner at the
clinical office are worldwide8). However, the laboratory
service requires multiple patient visits, similar to the
conventional indirect restoration. The use of temporary
restorations using temporary crowns and cement
restoration over multiple visits. Thus, determination of
the influences of one-day treatment without temporary
restoration and laboratory CAD/CAM restoration with
temporary restorations on the bonding of CAD/CAM
restorations is significant for the clinical application
of these two restoration approaches. In this context,
immediate dentin sealing has also been reported to
ameliorate the reduction in bond strength caused by the
application of temporary cement9,10). However, there is
no report that evaluate the influence of the immediate
dentin sealing and temporary cement on bonding under
condition which mimicked intraoral environment.
Measurement of bond strength is a method for
evaluating adhesive restorations. The microtensile bond
strength (μ-TBS) test introduced by Sano et al.11) is a
useful method for investigating internal bond strength
that is influenced by various intraoral stresses, such
as thermal and cyclic load stress12). In this regard,
the International Organization for Standardization
(ISO) technical specification 11405 guidelines state13)
that calculations of the probability of failure using the
Weibull distribution function are a suitable approach for
comparing many materials14).
This study aimed to examine the differences in
bonding behavior among CAD/CAM ceramic restorations
with and without immediate dentin sealing and
temporary restorations after cyclic loading, simulating
the intraoral condition, by measurement of μ-TBS
values, investigation of the bond reliability and
durability, and observation of the failure mode. The null
hypotheses of this study were as follows: 1) immediate
dentin sealing did not improve the bonding of CAD/CAM
ceramic crown restorations; 2) temporary restorations
did not have a negative influence on the bonding of CAD/

Received Sep 20, 2018: Accepted Jan 16, 2019

doi:10.4012/dmj.2018-313 JOI JST.JSTAGE/dmj/2018-313
 Dent Mater J 2019; 38(6): 970–980 971

CAM ceramic crown restorations. are shown in Table 1. For immediate dentin sealing,
a all-in-one adhesive system (Clearfil Universal Bond
MATERIALS AND METHODS Quick, Kuraray Noritake Dental, Tokyo, Japan) and a
low-viscosity resin composite (Clearfil Majesty ES Flow,
Experimental materials Kuraray Noritake Dental) were used. For temporary
The product name, composition, lot number, and restorations, a bis-acrylic composite (Protemp4
manufacturer details of each material used in this study Temporization Material, 3M, Seefeld, Germany) and

Table 1 Materials used in this study

Composition Lot no. Manufacturer

Immediate Dentin Sealing Materials

HEMA, Bis-GMA, MDP, Hydrophilic amide monomers,

Clearfil Universal Bond
Colloidal silica, Silane, AR0010
Quick Kuraray
Sodium fluoride, Ethanol, Water
Noritake
Barium grass filler, Silica filler, TEGDMA, Dental
Clearfil Majesty ES Flow
Hydrophobic-aromatic dimethacrylate, 9T0203
(Shade : A3)
Dl-Camphorquinone, Photo initator

Temporary Restoration Materials

Protemp4 Temporization Dimethacrylate polymer, Bis-GMA, Zirconia B 632665

3M
Material Silica, Fumed Silica, Silane, Pigments C 631021

Base: Zinc oxide, Carnauba wax

TempBond NE Accelerator: Rosin, Ortho-ethoxybenzoic acid, 5859290 Kerr
Octanoic acid.

Chair-side CAD/CAM System

CEREC AC Omnicam Dentsply

CEREC operating system software version 4.3 —
CEREC MC XL Sirona

Dental CAD/CAM Restorative Block

VITABLOCS MarkII Silicon dioxide, Aluminum oxide, Sodium oxide,

44910 VITA
(Shade: A3C) Potassium oxide, Calcium oxide, Titanium dioxide

Pretreatment Materials for Cementation

Porcelain Etchant Polyacrylamidomethylpropane sulfonic acid,

17000000304 BISCO
(9.5%HF) Hydrofluoric acid

Clearfil Ceramic Primer 3-trimethoxysilylpropyl methacrylate,

CA0011 Kuraray
Plus MDP, Ethanol
Noritake
PANAVIA V5 Tooth MDP, HEMA, Hydrophilic aliphatic dimethacrylate, Dental
2S0015
Primer Accelerators, Water

Adhesive Resin Cement

Paste A: Bis-GMA, TEGDMA, Silanated barium

glass filler, Silanated fluoroalminosilicate glass filler,
Hydrophobic aromatic dimethacrylate, Hydrophilic
aliphatic dimethacrylate, Colloidal silica, Initiators, Kuraray
PANAVIA V5
Accelerators 7M0008 Noritake
(Universal Shade)
Paste B: Bis-GMA, Silanated barium glass filler, Dental
Silanated alminium oxide filler, Hydrophobic aromatic
dimethacrylate, Hydrophilic aliphatic dimethacrylate,
Accelerators, Dl-Camphorquinone, Pigments

HEMA, 2-hydroxyethyl methacrylate; Bis-GMA, bisphenol-A-glycidyl methacrylate; MDP, 10-methacryloyloxydecyl

dihydrogen phosphate; TEGDMA, triethyleneglycol dimethacrylate.
972 Dent Mater J 2019; 38(6): 970–980

non-eugenol zinc-oxide cement (TempBond NE, Kerr,
Orange, CA, USA) were used. A chair-side CAD/CAM
system (CEREC AC Omnicam SW v4.3 and CEREC
MC XL, Dentsply Sirona, York, PA, USA) was used for
scanning, designing, and milling of the ceramic crown.
For the CAD/CAM block, the most feldspathic ceramic
block (VITABLOCS Mark II, VITA Zahnfabrik, Bad
Säckingen, Germany) was used. For pretreatment
before cementation, 9.5% hydrofluoric acid (Porcelain
Etchant, BISCO, Schaumburg, IL, USA) and a silane
coupling agent (Clearfil Ceramic Primer Plus, Kuraray
Noritake Dental) were applied to the inner surfaces
of the fabricated crowns. Next, a self-etching primer
(PANAVIA V5 Tooth Primer, Kuraray Noritake Dental)
was applied to the abutment surface according to the
manufacturer’s instructions. For cementation, a dual-
cure adhesive resin cement (PANAVIA V5, Kuraray
Noritake Dental) was used. For all-light irradiation, a
light-emitting diode (LED) curing unit (G-Light Prima
II, GC, Tokyo, Japan) in the “normal” mode with an
output of 900 mW/cm2 using a 13/8 mm diameter turbo
tip light guide was used. Before and after each light
irradiation, the light intensity was measured by a
radiometer (Demetron L.E.D. Radiometer, Kerr).
Tooth selection and experimental procedures
The use of human teeth in this study was approved by
the ethics committee of the Nippon Dental University
School of Life Dentistry, Tokyo (approval number: NDU-
T2016-06). Sixty human caries-free extracted lower
premolars that had similar size and color within one
year of storage in 0.1% thymol solution at 24°C after
extraction were selected and used. A schematic flow chart
of the experimental procedure is shown in Fig. 1. Each
tooth was set into a standardized cylindrical mold such
that the line connecting the top points of the mesiodistal
cervical line and the line connecting the lowest points of
buccolingual cervical line were parallel to the base plane
of the mold [Fig. 1-(a)].
Each tooth was embedded with an acrylic resin
(PROVINICE, Shofu, Kyoto, Japan) to 1 mm below from
lowest point of the cervical line. The intact coronal form
of each embedded tooth was scanned with a CEREC
AC Omnicam to reproduce the original form onto each

Fig. 1 Schematic flow chart of the experimental procedure.

Standardized CAD/CAM ceramic crown abutments were prepared and divided into two groups: an immediate
dentin sealing group (S+) and a non-sealing group (S−). A half of both S+ and S− specimens were temporarily
restored (T+) using a bisacrylic composite crown and a non-eugenol zinc-oxide cement, regardless of sealing
mode. The other specimens were not temporarily treated (T−). Each CAD/CAM crown was designed and
fabricated by a chair-side CAD/CAM system, and then cemented for each individual abutment. All restored
specimens were subjected to cyclic loading stress and then sectioned. A 1.0-mm-thick slab was obtained from
each specimen, and was trimmed into a standardized dumbbell-form specimen bonded to the occlusal dentin
wall. The μ-TBS was measured at a crosshead speed of 1.0 mm/min.
 Dent Mater J 2019; 38(6): 970–980
crown [Fig. 1-(b)]. Impressions of the tooth coronal
form were taken with a silicone impression material
(Exaflex Putty, GC) for confirmation of the tooth
volume redaction by the abutment preparation and for
fabrication of temporary crowns. The parallel-sided bur
of diameter 1.4 mm (FG211; ISO #: 110 070 014, mean
grit size: 100 μm; Shofu) was selected for preparation
of the occlusal surface, and the round-end diamond bur
of maximum diameter 2.1 mm designed for CAD/CAM
crown restoration (FG106RD, ISO #: 198 090 021, mean
grit size: 100 μm; Shofu) was selected for preparation
of the axial wall and margin. Standardized abutment
specimens were prepared using a custom-made abutment
and cavity duplicator (Tokyo Giken, Tokyo, Japan, Fig.
2) equipped with two types of diamond burs.
The abutment specimens were prepared according to
general method of CAD/CAM crown restoration15). First,
the tooth structure of the occlusal surface was removed
with FG211 to a depth of 1.5 mm [Fig. 1-(c)]. Then, the
axial wall with a rounded shoulder of 1.3-mm width was
prepared using FG 106RD. Diamond burs were replaced
every three abutment preparations. Subsequently,
all abutment specimens were divided into two groups;
an immediate dentin sealing restoration group (S+)
and a non-immediate dentin sealing restoration group
(S−) [Fig. 1-(d)]. The prepared dentin surfaces in the
S+ group were treated with a Clearfil Universal Bond
Quick and light cured for 10 s. Then, Clearfil Majesty
ES Flow (average: 17 mg) was applied to the pretreated
dentin surface with a standardized thickness using
a small brush, followed by light-curing for 20 s. The
unpolymerized superficial layer in the immediate
dentin sealing group was removed by a cotton pellet
soaked in 70% ethanol. All abutment specimens were
scanned using the CEREC AC Omnicam according to
Fig. 2 Custom-made abutment and cavity duplicator.
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the manufacturer instructions. Each ceramic crown was
designed using the duplicate function of CEREC AC
Omnicam and the data for the intact coronal form, and
milled with the CEREC MC XL [Fig. 1-(e)].
Next, half of the samples in both S+ and S− groups
were selected to form the temporary restoration group
(T+) [Fig. 1-(f)]. The other specimens were assigned to
the non-temporary restoration group (T−). For the T+
group, temporary crowns were fabricated individually
with an impression of a pre-prepared coronal form
and Protemp4 Temporization Material. The fabricated
temporary crowns were cemented to each specimen of the
T+ group using TempBond NE, and the samples of the
T+ restoration group were stored in water at 37°C for 1
week. After removal of temporary crowns, the abutment
surface of the T+ restoration group was cleaned with a
polishing brush (Merssage brush CA No.1, Shofu) under
water16). Individual ceramic crowns of the T− group
were cemented to the abutment without the temporary
restoration step.
Before cementation, each inner surface of the
fabricated ceramic crown was etched with Porcelain
Etchant for 90 s, rinsed, and air-dried. The etched
surfaces were treated with Clearfil Ceramic Primer
Plus. Every surface of all abutment specimens was
treated with the PANAVIA V5 Tooth Primer for 20 s,
and dried under a gentle flow of air. PANAVIA V5 resin
cement was applied to the inner surface of the ceramic
crowns, and the crown was pressed onto the abutment
under a certain force of 900 g for 1 min [Fig. 1-(g)]. After
removal of excess cement, each restored specimen was
light-irradiated from the occlusal, mesial, distal, buccal,
and lingual directions with G-Light Prima II for 10 s,
for a total irradiation period of 50 s. Then, each restored
specimen was polished with a series of polishing disk
(Sof-Lex XT, 3M), from coarse disk (#400 grit, 12.7 mm
diameter, 5,000 rpm) up to super fine disk (#1200 grit,
12.7 mm diameter, 5,000 rpm), and stored in 37°C water
for 1 h [Fig. 1-(h)].
Cyclic load and μ-TBS testing
For each restored specimen, an opposing object
was fabricated individually with an acrylic resin
(PROVINICE, Shofu) to load stress against the inner and
outer incline of the functional cusps of the ceramic crown.
All restored specimens were subjected to a cyclic load of
118 N over 90 cycles/min for a total of 3×105 cycles [Fig.
1-(i)]. This process was performed in water at 37°C using
a custom-made multi-function apparatus (Tokyo Giken).
Using a precision sectioning machine (IsoMet 1000,
Buehler, Lake Bluff, IL, USA), every restored specimen
was sectioned along the buccolingual dimension into a
slab specimen of 1.05-mm thickness including the bonded
interface at the inner incline of the functional cusps
(O) [Fig. 1-(j)]. Then, each remaining distal part of the
restored specimen was sectioned along the mesiodistal
dimension into a slab specimen of 1.05-mm thickness
including the bonded interface of the axial wall (A). The
obtained slab specimens were polished with a series of
silicone carbide papers up to #2000, and adjusted to a
974 Dent Mater J 2019; 38(6): 970–980

thickness of 1.0 mm. Each polished slab was trimmed
to a standardized dumbbell-formed specimen17) with a
cross-sectional area of 1.0×1.0 mm using a custom-made
test piece duplicator (Tokyo Giken) [Fig. 1-(k)]. Next, the
μ-TBS values of each specimen (n=15) were measured
at a crosshead speed of 1.0 mm/min using a universal
testing machine (Autograph AG-1, Shimadzu, Kyoto,
Japan) [Fig. 1-(l)].
Statistical analysis
The data distribution between two groups were
examined with F test and the distribution among three
groups were determined with Bartlett’s test. Then the
μ-TBS data were analyzed with Welch’s t-test, two-
way ANOVA, and Tukey’s HSD test using spreadsheet
software (Excel 2010 for Windows, Microsoft, Redmond,
WA, USA), with the level of significance set at 0.05%.
Furthermore, the Weibull parameters based on μ-TBS
values, namely, the Weibull modulus and the Weibull
stress values at 10 and 90% probability of failure (PF10
and PF90), were analyzed using the same spreadsheet
software to examine the bond reliability and durability.
Fracture mode observation
After μ-TBS measurements, the fracture mode of each
dumbbell-shaped specimen was observed using a light
microscope (Measurescope MM-11, Nikon, Tokyo,
Japan) at a magnification of 200×. Fracture mode was
classified to Ri: interfacial fracture occurring at the
interface between fabricated crown and resin cement; Cc:
cohesive fracture occurring within the resin cement; Ai:
interfacial fracture occurring at the interface between
abutment and resin cement.
RESULTS
Microtensile bond strength
Pre-testing failure was not recognized in this study.
The differences in the μ-TBS values between the CAD/
CAM restoration groups with and without immediate
dentin sealing or temporary restorations and between
the occlusal and axial abutment surfaces are shown in
Fig. 3. The μ-TBS values in the restoration group with
immediate dentin sealing (S+) were significantly greater
than those without immediate dentin sealing (S−). Thus,
immediate dentin sealing contributed to an increase in
the bond strength. On the other hand, no significant
difference was noted in the μ-TBS between the restoration
groups with and without temporary restoration and
between the occlusal (O) and axial abutment surfaces (A).
Thus, the application of temporary restorations did not
affect the bond strength, and the bond strengths to the
occlusal and axial abutment surfaces were equivalent.
Figure 4 shows the differences in the μ-TBS values
for the occlusal and axial abutment surfaces among the
four CAD/CAM restoration groups with and without
immediate dentin sealing and temporary restoration.
Temporary restoration did not affect the μ-TBS value
for the occlusal abutment surface, but immediate dentin
sealing significantly influenced the value. However, the
effect of immediate dentin sealing on the μ-TBS to the
occlusal abutment surface varied depending on the use
of temporary restorations. In the µ-TBS assessments for
the occlusal abutment surface in the T− group, the value

Fig. 3 Differences in μ-TBS between the CAD/CAM restoration groups with and
without immediate dentin sealing or temporary restoration and between
occlusal and axial abutment surfaces.
μ-TBS, micro-tensile bond strength; ( ), standard deviation; Two groups
connected with a straight line indicate a significant difference at p<0.05; S−:
a non-immediate dentin sealing restoration group; S+: an immediate dentin
sealing restoration group; T−: the non-temporary restoration group; T+: the
temporary restoration group; O: the inner incline of the functional cusps; A:
including the bonded interface of the axial wall.
 Dent Mater J 2019; 38(6): 970–980 975

in the S+ group was significantly greater than that in
the S− group. In contrast, the modes of immediate dentin
sealing and temporary restoration did not affect the
μ-TBS. Consequently, for the axial abutment surface,
no significant differences were recognized among the
μ-TBS values of the four restoration groups. There was
no significant difference in the μ-TBS values between
the occlusal and axial abutment surfaces, except in the
S−T− restoration group.

Bonding reliability and durability

Fig. 4 Differences in μ-TBS values for occlusal and axial
abutment surfaces among the four CAD/CAM
restoration groups with and without immediate
dentin sealing and temporary restoration.
μ-TBS, micro-tensile bond strength; ( ), standard
deviation; Two groups connected with a straight
line indicate a significant difference at p<0.05; S−:
a non-immediate dentin sealing restoration group;
S+: an immediate dentin sealing restoration group;
T−: the non-temporary restoration group; T+: the
temporary restoration group; O: the inner incline
of the functional cusps; A: including the bonded
interface of the axial wall.
Figure 5 presents the differences in the Weibull
parameters, i.e., the Weibull modulus and the PF10 and
PF90, between the CAD/CAM restoration groups with
and without immediate dentin sealing or temporary
restoration and between the occlusal and axial abutment
surfaces. The Weibull modulus, PF10, and PF90 values in
the S+ restoration group were significantly greater than
those in the S− restoration group. The Weibull modulus
and PF10 values in the T− restoration group were
significantly greater than those in the T+ restoration
group, although no significant difference was noted
in the PF90 values of these two restoration groups. In
contrast, the values of the Weibull parameters did differ
between occlusal and axial abutment surfaces.
Figure 6 shows the differences in Weibull modulus,
PF10, and PF90 (95% confidence intervals, lower-upper
limit values), for the occlusal abutment surface among
the CAD/CAM restoration groups with and without
immediate dentin sealing and temporary restorations.
Weibull modulus and PF10 values decreased in the
following order: S+T−>S+T+>S−T−>S−T+, and the
values in the S+T− group were significantly greater
than those in the other restoration groups. Significant
differences were noted in the Weibull modulus values

Fig. 5 Differences in Weibull parameters between the CAD/CAM restoration groups

with and without immediate dentin sealing or temporary restoration and
between occlusal and axial abutment surfaces.
Values with different letters in the same column indicate a statistically
significant difference at p<0.05. Wm, Weibull modulus; PF10, PF90, the
Weibull stress value in MPa for 10 and 90% probability of failure level; S−:
a non-immediate dentin sealing restoration group; S+: an immediate dentin
sealing restoration group; T−: the non-temporary restoration group; T+: the
temporary restoration group; O: the inner incline of the functional cusps; A:
including the bonded interface of the axial wall.
976 Dent Mater J 2019; 38(6): 970–980

Fig. 6 Differences in Weibull parameters for occlusal
abutment surfaces among CAD/CAM restoration
groups with and without immediate dentin sealing
and temporary restoration.
Values with different letters in the same column
indicate a statistically significant difference at
p<0.05. Wm, Weibull modulus; PF10, PF90,
the Weibull stress value in MPa for 10 and 90%
probability of failure (95% confidence interval); S−:
a non-immediate dentin sealing restoration group;
S+: an immediate dentin sealing restoration group;
T−: the non-temporary restoration group; T+: the
temporary restoration group; O: the inner incline
of the functional cusps.
Fig. 7 Differences in Weibull parameters for axial
abutment surfaces among four CAD/CAM
restoration groups with and without immediate
dentin sealing and temporary restoration.
Values with different letters in the same column
indicate a statistically significant difference at
p<0.05. Wm, Weibull modulus; PF10, PF90,
the Weibull stress value in MPa for 10 and 90%
probability of failure (95% confidence interval); S−:
a non-immediate dentin sealing restoration group;
S+: an immediate dentin sealing restoration group;
T−: the non-temporary restoration group; T+: the
temporary restoration group; A: including the
bonded interface of the axial wall.

Table 2 Fracture mode distribution observed using light microscopy

Immediate dentin sealing mode S− S+

Temporary Restoration mode T− T+ T− T+

Number of specimen Amount (Occlusal / Axial wall)

Ri 1 (0/1) 2 (0/2) 1 (0/1) 0 (0/0)

Ri + Cc 26 (13/13) 21 (11/10) 21 (9/12) 25 (11/14)

Mixed Ri + Cc + Ai 0 (0/0) 0 (0/0) 2 (1/1) 2 (1/1)
Cc + Ai 2 (1/1) 6 (4/2) 6 (5/1) 1 (1/0)

Cc 1 (1/0) 1 (0/1) 0 (0/0) 2 (2/0)

Ri: interfacial fracture occurring at the interface between fabricated crown and resin cement; Cc: cohesive fracture occurring
within the resin cement; Ai: interfacial fracture occurring at the interface between abutment and resin cement; S−: a non-
immediate dentin sealing restoration group; S+: an immediate dentin sealing restoration group; T−: the non-temporary
restoration group; T+: the temporary restoration group.

of the S+T+ and S−T+ restoration groups. On the other
hand, the PF90 values decreased in the following order:
S+T−>S+T+>S−T+>S−T−, and the PF90 value of the
S+T− restoration group was significantly greater than
the values in the other restoration groups. Therefore,
for the occlusal abutment surface, the S+T− restoration
group showed maximal bond reliability in achieving a
specific μ-TBS value for a restoration and durability
against debonding.
Figure 7 shows the differences in Weibull modulus,
PF10, and PF90 (95% confidence intervals, lower-upper
limit values) for the axial abutment surfaces among the
four CAD/CAM restoration groups with and without
immediate dentin sealing and temporary restoration.
The values for the Weibull parameters decreased in the
following order: S−T−>S+T−>S+T+>S−T+ for Weibull
modulus, S−T−>S+T−>S+T−>S−T+ for PF10, and
S+T−>S+T−>S−T+>S−T− for PF90.
 Dent Mater J 2019; 38(6): 970–980
The fracture mode distribution of the specimens
The distribution of the failure modes observed under
a light microscope are presented in Table 2. Cohesive
fracture within immediate dentin sealing layer was not
recognized. Regardless of the restoration, most of the
post-test specimens exhibited mixed fractures consisting
of interfacial fracture occurring at the interface between
fabricated crown and resin cement and cohesive fracture
occurring within the resin cement. The number of mixed
fractures consisting of interfacial fracture occurring at
the interface between fabricated crown and resin cement
and interfacial fracture occurring at the interface between
fabricated crown and resin cement was 26 (87%) for the
S−T− group; 25 (83%) for the S+T+ group, 21 (70%) for
the S−T+ group, and 21 (70%) for the S+T− group.
DISCUSSION
This study clarified that 1) immediate dentin sealing
improved the bonding of CAD/CAM ceramic crown
restorations; 2) temporary restorations did not have
a negative influence on the µ-TBS values, whereas
it decreased bonding of CAD/CAM ceramic crown
restorations in the qualitative evaluation.
Efficacy of immediate dentin sealing on the bonding of
CAD/CAM ceramic crown restorations
Metal-free restorations require robust and reliable
adhesion for excellent prognosis. Immediate dentin
sealing contributed to achieving robust μ-TBS values for
the bonding interface in this study (Fig. 3). Murata et
al.18) reported that the immediate dentin sealing layer
between the resin cement and dentin acts as a stress
breaker for external forces, such as those generated
by mastication, and contributes to an improvement in
μ-TBS by functioning as a stress breaker in CAD/CAM
ceramic onlay restorations.
The cyclic loading in this study was set at 118 N at
90 cycles/min for a total of 3×105 cycles. Previous studies
have reported that the human chewing motion generates
stress equivalent to 70–150 N19,20), which is repeated
60–90 times per minute21,22). In addition, Sakaguchi et
al.23) reported that the average cycle of human chewing
motion per year was approximately 2.5×105 times.
Therefore, the setting of cyclic loading used in this study
corresponds to clinical loading or more severe loading in
the oral environment over 14 months without sleeping
or resting.
Large differences in the elastic modulus values
among the fabricated crown elements, cement, and
the tooth substrate produce substantial stress at both
interfaces and the stress decreases the µ-TBS under
the cyclic load condition. Dong et al.24) concluded that
approximation of the elastic modulus between the
cement and bonded material reduces the risk of bonding
failure. The elastic modulus values of the restorative
materials and tooth substrate used in this study are as
follows; feldspathic ceramic block, 45 GPa25); adhesive
resin cement, 6.3 GPa26), flowable resin composite used
for immediate dentin sealing, 7.4 GPa12); and dentin,
977
16–18 GPa27,28). The elastic modulus of the flowable
resin composite is smaller than that of dentin and is
slightly larger than that of the adhesive resin cement.
Consequently, the reduction in the difference between
the elastic modulus values of the between dentin and
adhesive resin cement mediated by the use of flowable
resin composite for immediate dentin sealing helped
achieve a robust μ-TBS.
The laboratory environment represents an ideal set
of conditions in comparison with the oral environment
of the patient. Previous studies2,9,10,16) have examined
adhesion using the mean values of bond strength as a
representative parameter, regardless of stress loading.
Assessments using mean values represent a quantitative
evaluation of the adhesion. However, for evaluation of
adhesion, in addition to quantitative determination,
qualitative investigations, e.g., reliability analysis, are
important. The Weibull analysis is especially helpful
in evaluating reliability14). It is characterized by two
principal parameters: the Weibull modulus, which can
predict the reliability of a bond, and the Weibull stress
values required to cause a failure, which evaluate
the performance of a bond at certain percentage level
e.g., 10% level, 63.2% level, 90% level. A high Weibull
modulus value is desirable for all materials because it
indicates greater homogeneity in defect distribution
and greater predictability of failure behavior29). Inokosi
et al.30) reported that higher Weibull modulus values
indicate better bond reliability. In addition, the ISO/
TS 1140513) suggested that stress values calculated
at the 10 and 90% failure levels (PF10 and PF90) in
data evaluations using Weibull analysis are useful for
characterizing the strength of the bond. The application
of immediate dentin sealing helped improve Weibull
modulus, PF10, and PF90 (Fig. 5). Therefore, immediate
dentin sealing should be effective in improving both
quantitative and qualitative states of adhesion in CAD/
CAM crown restorations.
In comparison with metal crown restorations,
ceramic crown restorations require a large amount
of tooth reduction to ensure mechanical strength and
esthetics of the restoration. Ceramic crown restorations
show excellent esthetics when applied on vital teeth in
25–72% of the clinical cases31-35). The large amount of
tooth reduction for vital teeth exposes the deep dentin,
and may cause injury to the dentin pulp complex because
of external stimulations such as thermal and mechanical
irritations, rarely leading to pulp necrosis. The deep
dentin surface coating provided by immediate dentin
sealing helps prevent postoperative sensitivity. Thus,
immediate dentin sealing for CAD/CAM ceramic crown
restorations allows both preservation of the adhesion
and protection of the dentin pulp complex.
Influence of temporary restorations on the bonding of
CAD/CAM ceramic crown restorations
For conventional indirect restorations, temporary
restoration is usually applied to the abutment after the
impression until the next chair-time visit36,37). Although
digital dental treatment enables one-day treatment
978 Dent Mater J 2019; 38(6): 970–980
and completion of the restoration in a single visit,
laboratory CAD/CAM restorations8) based on digital
data obtained chair-side with an intraoral scanner are
currently. However, methods based on laboratory CAD/
CAM restorations require multiple visits, similar to a
conventional indirect restoration. Thus, the abutment
needs to be protected by a temporary restoration until
the next visit. The aims of temporary restorations include
pulpal protection, preservation of tooth substrate,
restoration of occlusal function, and maintenance of
esthetics36,37). Although temporary cement has been
reported to decrease the bond strength of resin cement
for the final restoration38,39), these results were based on
measurements obtained after storage of specimens in
water without any stress loading. This study evaluated
the influence of temporary restoration by assessing the
μ-TBS values for specimens restored with fabricated
crowns after cyclic loading. The mode of temporary
restoration did not significantly affect the mean
μ-TBS value (Fig. 3). In theory, contamination with
temporary cement increases the number of fractures
including the abutment surface. However, the number
of fractures including the abutment surface was almost
equivalent between the non-temporary restoration
group (10 specimens) and temporary restoration group
(9 specimens) in this study (Table 2). Accordingly, the
cleaning method employed in this study, i.e., cleaning
with a polishing brush under water16) was effective in
removing the harmful effect of the temporary cement.
However, in the qualitative evaluations, the
temporary restoration decreased the Weibull modulus
and PF10 values (Fig. 5), indicating that while
contamination with temporary cement did not affect the
μ-TBS, it had a negative effect on the bond reliability
and the bond durability at a low probability level of
failure. Therefore, thorough removal of the temporary
cement and sufficient follow-up will be required to
determine the final prognosis of CAD/CAM restorations
with temporary restoration.
Influence of difference between occlusal and axial walls on
the bonding of CAD/CAM ceramic crown restorations
Difference between occlusal and axial walls did not affect
the mean μ-TBS values (Fig. 3). In any restoration of the
four groups, the μ-TBS for the axial surface tended to
be larger than the value for the occlusal surface (Fig. 4).
However, bond reliability, based on the Weibull modulus
value, of occlusal surfaces was significantly superior to
that of axial surfaces, and the PF10 values showed no
significant differences between the occlusal and axial
surfaces. The PF90 value of the occlusal surface was
significantly smaller than that of the axial surface (Fig.
5). Thus, severe cyclic loading set at 118 N had different
influences on the bond reliability and durability of the
two types of abutment surfaces. In the occlusal surface,
where the cyclic load exerted a vertical force, the bonding
was damaged uniformly; the bond reliability, including
the negative factor, increased with a homogeneous
degradation; and the bond durability at a high probability
level of failure decreased simultaneously. In contrast, in
the axial surface, where the cyclic load stress exerted a
horizontal force, the damage to bonding due to the shear
stress caused by cyclic loading was small because the
CAD/CAM crown material had a largish elastic modulus
(45 GPa25)). Consequently, the bond reliability, including
the positive factor, decreased with a slight degradation,
and the bond durability at a high probability level of
failure increased.
Influence of CAD/CAM restoration with and without
immediate dentin sealing and temporary restoration in
the occlusal abutment surface on bonding
The non-temporary restoration group in this study can be
considered to be representative of one-day treatment6,7)
with a chair-side CAD/CAM system. The immediate
dentin sealing improved the μ-TBS, Weibull modulus,
PF10, and PF90 values in this group (Figs. 4, 6). One-
day treatment may serve as a more gentle restoration
method for patients because of the impression-material-
free treatment, single-visit protocol, and high-quality
esthetics7).
The temporary restoration group in this study can
be considered to be representative of laboratory CAD/
CAM restorations8), which require multiple visits.
Immediate dentin sealing did not affect the μ-TBS in
the temporary restoration group (Fig. 4). In contrast,
the Weibull modulus and PF10 values increased with
immediate dentin sealing (Fig. 6). Thus, the efficacy of
immediate dentin sealing in temporary restorations was
inapparent in quantitative evaluations but was revealed
by a qualitative assessment. Immediate dentin sealing
also ameliorated the bond strength reduction caused by
the application of temporary cement9,10). This may be
attributable to the ability of immediate dentin sealing
to prevent the invasion of temporary cement into the
dentinal tubules. Thus, immediate dentin sealing might
decrease the inapparent influence of temporary cement,
which was undetectable in quantitative evaluations.
Although there was no significant difference in
the μ-TBS values between the non-temporary (one-day
treatment) and temporary restoration (laboratory CAD/
CAM restoration) groups under the immediate dentin
sealing condition (Fig. 4), the non-temporary restoration
group showed superior Weibull modulus, PF10, and
PF90 values (Fig. 6). Thus, a single application of
immediate dentin sealing may not be sufficient to
completely prevent the qualitative degradation caused
by the temporary cement. However, the prepared
dentin surface coated by immediate dentin sealing was
protected against external stimulation by the layer of
flowable resin composite. Therefore, the coated surface
can be cleaned with a chemical method using phosphoric
acid or other material.
Influence of CAD/CAM restoration with and without
immediate dentin sealing and temporary restoration in
the axial abutment surface on bonding
The magnitude relationships of Weibull modulus, PF10,
PF90 values among the four restorations revealed
different behaviors (Fig. 7) in occlusal and axial surfaces.
 Dent Mater J 2019; 38(6): 970–980
For the occlusal surface, the cyclic loading exerts its
effects vertically, with the effects occurring directly on
the luting zone, which consists of an interface between
the surface and resin cement, the inner side of the
resin cement, the interface between the resin cement
and abutment surface or the immediate dentin sealing
material, and the interface between the immediate
dentin sealing material and the dentin surface via
the restoration. Homaei et al.40) examined the stress
distribution of metal-free crown restorations in premolars
by using finite-element analysis and reported that the
occlusal surface was most influenced by loading. For
the axial surface, the stress behavior would be different
because the loading stress is dispersed circumferentially
over a broad margin.
The fracture mode distribution of the measured
specimens
Mixed fractures consisting of Ri and Cc were observed
on 97 sample surfaces (81%, Table 2). Therefore, the
weakest part where bonding failure occurred might be
the surface or the inner side of the resin cement. This
study employed pretreatment with hydrofluoric acid
and a silane coupling agent to the internal surface of
feldspathic ceramic crowns, which is the global standard
method36,37). Accordingly, some novel materials and a
technique based on a new concept may be necessary
to improve bonding. In addition, reinforcement of the
mechanical properties of resin cement may help decrease
the occurrence of Cc. This might be a useful strategy to
improve quantitative and qualitative bonding.
CONCLUSION
Immediate dentin sealing contributed to an increase
in the bond strength. The application of temporary
restorations did not affect the bond strength, and the
bond strengths for the occlusal and axial abutment
surfaces were equivalent. The mode of temporary
restoration did not affect the μ-TBS values for the
occlusal abutment surface, whereas the mode of
immediate dentin sealing significantly affected the
values. The effect of immediate dentin sealing on the
μ-TBS for the occlusal abutment surface did vary with
the mode of temporary restoration. For axial abutment
surfaces, the mode of both immediate dentin sealing and
temporary restoration did not affect the μ-TBS values.
Consequently, no significant difference was recognized
among the μ-TBS values of the four restoration groups.
The Weibull modulus, PF10, and PF90 values of the S+
restoration group were significantly greater than the
corresponding values in the S− restoration group. For
occlusal abutment surfaces, the S+T− restoration group
showed the most superior bond reliability for achieving
specific μ-TBS values of the restoration and bond
durability against debonding.
ACKNOWLEDGMENTS
This study was partially supported by the Japan Society
979
for the Promotion of Science (KAKENHI Grant Number
17K11719).
CONFLICTS OF INTEREST
The authors do not have any financial interest in the
companies whose materials are mentioned in the
article.
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